Saturday, October 6, 2018 – Recovering from a very busy day with dinner at Gibb’s Farm…

Standard

Saturdays are typically much slower at FAME so we were all looking forward to a bit of a break after the busy day we had had yesterday. We had all walked up to meet for morning report but soon discovered that all of the doctors hadn’t yet arrived so we would just begin our Saturday neurology clinic a bit early. We had promised the group of women from Arusha that we would see them first today and there were about fifteen patients who had come the day before that we couldn’t see and were told to come back this morning. I learned from Angel that you can’t take names and promise anyone anything as then patients may not come first thing in the morning and may wait until much later in the day to show up causing major issues with our scheduling. So, patients were told to merely show up again first thing in the morning and we do are best to get them in as soon as was possible. We also had dinner plans this evening at Gibb’s Farm and it is a must to get there before sunset so we could sit on the veranda drinking our Moscow Mules or whatever else tickled one’s fancy before heading off to an incredible dinner. Therefore, we clearly had some excellent incentive to finish clinic on time or earlier, if possible.

Amisha, Lindsay and Shaban caring for a young child

Despite it being Saturday and seeming as though we had thoroughly stamped out neurologic disease in Karatu yesterday with our clinic, there were still quite a few patients waiting to be seen when we arrived to the emergency area where we hold our clinic. With Angel’s assistance, we decided that we would cap today’s clinic at around thirty patients, which typically means that you’ll see a few extra as they are sent to us from the outpatient clinic throughout the day. Luckily, though, there were few of these over the course of the day meaning that we would very likely finish on time.

Lindsay and Kitashu evaluating a patient

In the afternoon, Amisha was asked to consult on a three-month-old Maasai baby in the ward who had presented with a history of fever and obtundation and would definitely need an LP as we felt very strongly that the baby had meningitis. We have no ability yet to culture here, so the LP would really be done to characterize things rather than to catch a specific bug. The baby had a bulging fontanelle and had seized and clearly had meningismus along with axial rigidity. He had already received the appropriate antibiotics when Amisha first saw him and later in the evening we also added another antibiotic for better coverage. Amisha brought the baby over to the emergency room so we could do the procedure there, but John was still seeing patients, so he eventually moved along with his patient to an outer room that is very small and is typically used for obtaining vitals. You have to learn to go with the flow here and so if moving to another room along with your patient will allow someone else the ability to care for a patient in need, then that’s what you do.

Amisha performing an LP with Steve’s assistance

We set up for the spinal tap and enlisted Steve to help us with the procedure, as well as the case in general given the fact that we were fairly certain that we were dealing with an infectious process. Steve, of course, would repeatedly remind us that he doesn’t treat children. This is clearly reminiscent of my first visit here only to find that one morning they had a long line of children that had been referred to me from Loliondo, a district north of here by the Kenyan border. Though I have cared for children for my entire career, I did point out to Frank that I’m not a pediatric neurologist. His reply was something that has been permanently imprinted in my brain: “No, but you’re the closest thing to a pediatric neurologist that we have in all of Tanzania right now.” I think this is probably a corollary to TIA (this is Africa), and something that does make practical sense here where it wouldn’t fly for one second in the States, where one would never consider wandering out of their comfort zone while treating patients. Steve pitched in completely in the care of this child and assisted in the LP which went incredibly smooth.

Amisha collecting fluid

Amisha completed the spinal tap without difficulty and obtained the necessary fluid to send to the lab so we would have a better of what we were dealing with. The fluid was surprisingly clear considering what our suspicions were, but we would have to wait for the results from the lab to make any decisions in the child’s treatment plan. He was on phenobarbital for the seizures and antibiotics for the presumed meningitis and it was now more of a waiting period for the child to improve or to have some labs back that would send us in another direction.

Dr. Anne learning the fine points of neuro-ophthalmology

John saw a patient today who had developed a severe headache followed five days later by unilateral ptosis (droopy eyelid), diplopia and a large fixed pupil that had come to FAME one month prior and underwent a CT scan that was normal. This is a clinical scenario that is fairly classic for a posterior communicating artery that is compressing the third nerve and causes a fixed and dilated pupil, ophthalmoplegia (weakness of specific eye muscles controlled by the third cranial nerve) and ptosis, or drooping of the eyelid on that side. The plain CT scan essentially ruled out any bleeding, though one could argue that she didn’t appear to have a subarachnoid hemorrhage when she came to clinic. The other possibility would be that she didn’t have a subarachnoid hemorrhage, but rather a thrombosed aneurysm that had suddenly enlarged and compressed the third nerve, producing the physical findings we saw here. She desperately needed to have a vascular imaging study, but unfortunately that is not something that is available here, or in any part of Northern Tanzania for that matter. We did the next best thing, though, and requested that she undergo a contrasted CT scan that would give us some of the information we were looking for, if not all.

Hannah and Dr. Anne evaluating a patient

Lindsay, John and I sat in front of the monitor on the CT scanner scrutinizing the axial and coronal cuts knowing pretty much what we were looking for and just couldn’t see anything there. We were looking for an aneurysm, or enlargement of the posterior communicating artery, that would be compressing the third cranial nerve and causing the patients deficits on exam. At home, we’d have a CT angiogram that would give us detailed imaging of the blood vessels and, if there were something amiss, we’d be able to see it in multiple views and angles. Here, though, we were looking at a very much less than optimal imaging study that would show us what we needed if we were lucky. I took videos with my iPhone of each of the CT sequences as I clicked through them, an incredibly crude, but effective technique that I just learned from the residents as this is often what they do at home to send quick images to their supervising residents or fellows when on call. Sending actual CT studies by email is impossible as the data is so large, so these pictures or videos will have to suffice for the moment.

Shaban learning the neurological examination

Later, I sent the videos and details of the case by email to Sean Grady, chair of neurosurgery at Penn and a long-time friend since our days training at the University of Virginia, to get his opinion. He got back to me almost immediately after having reviewed the images and agreed with us that there was nothing in the area of interest. Unfortunately, that doesn’t mean that the patient is out of the woods as she may very well still have an aneurysm compressing the third nerve, but because it is thrombosed, or essentially filled with clot, we just can’t see it on our contrasted CT scan due to the low sensitivity of the study in this area where there is a lot of artifact from bone. We will have to relay our recommendations to the patient that she travel to Dar es Salaam to see the only neurosurgeon in the country, or possibly to Nairobi if they can afford it, to hopefully have the correct studies, and, if she does have an aneurysm there, have it clipped to prevent a later rupture and subarachnoid hemorrhage. Unfortunately, the options are very limited and, as is all too often the case here, she will choose not to go to Dar and will have to roll the dice, hoping that nothing catastrophic happens in the future. If the gods are will her, she might do well, but it is a big chance to take and not one that any of us would choose in this situation.

Hannah modeling with Turtle (our Land Rover) and ready for a night at Gibb’s

Our clinic was finally over and we were all looking forward to our trip up to Gibb’s Farm. This is a working coffee plantation and farm that has been in existence for many years and has become our favorite place to relax and wind down after days of seeing patients. It is one of the many safari lodges here in Karatu that cater to the many tourists who have come to see the wonderful wildlife parks of Northern Tanzania – Tarangire, Manyara, Ngorongoro Crater and the Serengeti. Karatu sits on the small highway that traverses the landscape here and the tarmac (pavement) ends just beyond the village as you ascend the crater rim heading to the Ngorongoro Gate and eventually into the Crater or on to the Serengeti traverses the Ngorongoro Conservation Area before you reach the most magnificent of wildlife parks and home of the great migration of wildebeest and zebra, the largest land migration on earth.

Drinks on the veranda with our jacaranda tree in the background

The management at Gibb’s Farm has been quite gracious in that they allow volunteers from FAME to come enjoy their amenities for a reduced rate as a way of saying thanks for what FAME is doing for the community here. Spending an evening at Gibb’s is something that is very difficult to describe and must be experienced to really understand the effect this incredibly lovely resort has on your mind and body. Just writing about it is relaxing to me as I imagine all of the images there. I first visited there in 2009, and have been fortunate enough to go back on each of my return visits to Tanzania. There have been changes over the years, but all for the better, and perhaps one of my favorite spots on here or anywhere on this planet. We arrived just before sunset so everyone could take in the amazing view from the lawns in front of the main lodge building and then sat at one of the two large tables on the veranda, overlooking the lawns. A very large jacaranda tree loomed high above our heads with its almost fluorescent lavender blooms glowing in the dimming light. The sounds of the birds and animals filled the air and for the moment it was difficult to even imagine that anything else existed in the world.

We sat having our drinks, mostly Moscow Mules in their copper mugs, all realizing just how incredibly fortunate we were to be here and share this experience. It never gets old for me, but knowing that the others are experiencing it for the first time is enough to make it seem like it’s my very first visit and something fresh and new. Somehow, we began to talk about birthdays at some point and Steve divulged that today was actually his birthday and he had just decided not to tell anyone. On my next trip inside to order drinks (totally unnecessary as we were waited on hand and foot), I let them know that it was his birthday and asked if they could have the staff come and sing to him along with maybe a small cake after dinner. The plot was set and I was confident that Steve was completely unaware that anything was amiss. We sat outside until well after it was dark having our second round of drinks, just enjoying each other’s company, and finally went inside well after 7:30 to sit at our table for dinner. Before that, though, we all went up to visit one of the artist’s studios who I had purchased something from before. He is a lovely man who I had met there several years ago and visit every time I’m here. Last spring, he had a child here at FAME so I was able to see him here and congratulate him.

Steve realizing it’s his celebration

Dinner was a wonderful affair as everything is locally grown and very fresh. Every course was incredibly scrumptious and the staff were so attentive that we were in need of absolutely nothing throughout dinner having an ample supply of fresh baked bread and butter. Before desert was to be served we heard the staff back in the kitchen begin their procession that I have so many times. “Jambo, Jambo Bwana, Mzuri sana….” This is their welcoming song for the mzungu and tourists that I’ve heard at birthdays and after coming off of Kilimanjaro following our summitting three years ago. The staff danced throughout the dining area and among the other guests banging pots for drums with everyone singing the words and clapping. Steve was enjoying the whole affair, completely unaware that the celebration was for him, clapping and singing along and completely unaware that Amisha, sitting directly across from him, was videoing the entire event to catch his reaction. As the procession eventually made it to our table and the staff surrounded Steve, he finally became aware that they were celebrating his birthday and he had such a look of total surprise. It was such a genuine moment and all of us were so grateful that we were able to share his birthday with him as he had planned to let it slip by without notice. It also reminded me of my sixtieth surprise birthday party here two years ago in March that Jess, Jackie and Paulina masterminded without a hint of awareness by me. I think these are the times that we cherish the most and realize just how much each of us is appreciated. They are the times that we allow those who love and respect us to express themselves and honor us. They are the times that we will always remember.

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We drove home from Gibb’s fully satiated both physically and spiritually. We were leaving early in the morning to go on safari in Lake Manyara National Park and would have to make our lunches for the trip. Also, Amisha wanted to check on the little baby with the presumed meningitis so I walked up the hospital with her while the others worked on our peanut butter sandwiches and hardboiled eggs for tomorrow. It had been a great day and evening and we all slept very well with dreams of wild animals and incredible sights.

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